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I hesitated to share this commentary on the TC blog as I know anyone who questions the efficacy and safety of e-cigarettes is tarred and feathered as a “quit-or-die” prohibitionist before the “ink” even settles on the page. But, as many online commentators have discussed the perceived positive effects of recent e-cig promotion by celebrities, I think it is important to provide some balance to this discussion.

I implore all readers to remember that I speak strictly from the Australian context and perhaps the political and social context are different in your neck of the woods. Myself, Tobacco Control and the BMJ wholeheartedly welcome all civil debate.

This commentary was originally published on 11 April 2011 by the not-for-profit news and information service, The Conversation. I am the sole author and these opinions are strictly my own and not that of Tobacco Control.

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On a recent long-haul flight, with very limited movie options, I watched the Angelina Jolie and Johnny Depp movie The Tourist (two thumbs firmly down).

A particular scene on a train to Venice did catch my eye. Jolie’s character boards the train and sits across from what appears to be a cigarette smoking Depp. It immediately jumped out at me as quite strange – smoking openly on public transport has long been banned and this movie is set in present day.

Depp’s character then clarifies that he is in fact smoking an electronic cigarette, “It’s ok, it’s not a real cigarette. It’s electronic. It delivers the same amount of nicotine but the smoke is water vapour.”

http://www.youtube.com/watch?v=iMlf5KSp5X4

Which again, I found rather strange – was this a case of product placement or a scriptwriter who wanted to offer a detailed description of what Depp was smoking?

This is not the first time a celebrity has spruiked the virtues of electronic cigarettes. In 2010, American actress Katherine Heigl appeared on The Late Show with David Letterman and demonstrated how to use and explained the inner workings of her electronic cigarette.

She then went on to say that smoking an electronic cigarette was as harmless as drinking coffee and that “it’s not bad for you, so it’s a fun addiction.”

http://www.youtube.com/watch?v=QxZjGUiaIS0

Using glamorous and famous actors to promote cigarettes dates back to golden years of Hollywood when the likes of Clark Gable, Joan Crawford, Gary Cooper, Spencer Tracy and John Wayne were all paid to smoke cigarettes.

Could the same be happening with e-cigarettes? Even if no money is formally changing hands, celebrities can have a profound influence on consumer buying habits.

For the unfamiliar, electronic cigarettes, or e-cigarettes more commonly, are battery operated devices that vaporise cartridges of liquid nicotine.

They look very similar to traditional cigarettes except they are plastic and have a small LED light on the end – assumedly to look even more authentic.

Even the advertising campaigns for these products are reminiscent of old school cigarette ads – featuring young men and women suggestively posing with the device.

Because nicotine is a scheduled poison in Australia, e-cigarettes are banned for sale within Australian retail outlets. Scheduled poisons are tightly controlled and can’t simply be sold in any retail outlet to anyone who wants them.

Determined e-cigarettes buyers can easily go online and make a purchase from hundreds of websites and eBay sellers. But they don’t come cheap and can cost upwards of $120, plus the nicotine cartridges must be continually reordered.

In a paradoxical twist, the most harmful form of nicotine delivery, tobacco prepared and packed for smoking, is excluded from the poison schedule.

Nicotine replacement products, such as the patch, gum and inhaler, which have undergone extensive medical testing and proven to be both safe and effective in helping people quit smoking, are also allowed to be marketed and sold in Australia.

Proponents of e-cigarettes argue that they are “safer” than real cigarettes and therefore should be permitted for sale. Smokers are encouraged to swap their cigarettes for these products.

It’s true, there are few legal consumer products as harmful to health as cigarettes. But the potential risks or benefits of e-cigarettes are unknown.

E-cigarettes have not been submitted to the same rigorous safety testing as medical nicotine products and their efficacy in helping smokers quit is almost entirely anecdotal.

A search of blogs discussing e-cigarettes will nonetheless reveal zealous and enthusiastic e-cigarette users who argue that “vaping” (the slang term for the act of “smoking an e-cigarette) is the only answer to ending tobacco use.

The marketing and promotion of e-cigarettes belies the supposed intention that these products are only for addicted smokers who are unable to quit on their own. They promote nicotine addiction as a harmless and fun activity.

These products may also encourage smokers who would have otherwise have completely quit, to keep smoking.

It’s not hard to imagine a smoker substituting an e-cigarette for a few of their preferred, regular cigarettes and to keep on smoking, rationalising that they have cut down their tobacco use.

One of the most important effects of Australia’s highly effective campaign to reduce tobacco is that smoking is no longer considered a normal or socially acceptable activity.

E-cigarettes have the very real potential to derail this success and have not been proven to be a necessary or effective part of reducing tobacco use.

Substantial tax increases on tobacco products, strong legislation, like the newly announced plain packaging of tobacco products, and hard-hitting media campaigns have all been proven to bring smoking rates down in Australia.

Selling smokers unfounded promises of a miracle cure cannot be a foundation for public health policy.

“Because nicotine is a scheduled poison in Australia, e-cigarettes are banned for sale within Australian retail outlets.”

– That may be the given reason but, by listing all the exemptions, you show that in reality it is only e-cigarettes and oral snuff that is banned.

“The marketing and promotion of e-cigarettes belies the supposed intention that these products are only for addicted smokers who are unable to quit on their own. They promote nicotine addiction as a harmless and fun activity.”

– I'd be interested to see examples. I'm sure there are a few, but this is clearly a regulatory issue. There is no reason to have an outright ban of a product in order to prevent misleading marketing.

“These products may also encourage smokers who would have otherwise have completely quit, to keep smoking.”

– That may happen in some cases, but it is an accusation that could equally be levelled at pharmaceutical nicotine products. In both cases, users are more likely to give up altogether.

“But the potential risks or benefits of e-cigarettes are unknown.”

– Why, then, doesn't tobacco control divert a few million dollars away from studying such things as 'thirdhand smoke' and carry out some serious research into the efficacy and safety of e-cigarettes? They have been on the market for some years and many, many people have found them effective as stop-smoking aids. Isn't this the kind of thing health organisations should be getting excited about?

In any case, there is such a thing a real world experience. E-cigarettes have been around for years without any reports of death or ill health. Last year's Tobacco Control study raised a few minor concerns about the packaging of some brands but this, again, is a routine issue of product regulation.

I don't think the apparent a priori negativity towards e-cigs in the article is justified.

If we had Johnny Depp/her from Grey's anatomy using a Nicorette inhalator (which in the UK is indicated for use in harm reduction http://bit.ly/jiKhFo ) prominently in the public view, highlighting to current smokers that lower-harm forms of nicotine delivery exist, wouldn't that be a good thing from a public health pov?

Yes, there are more unanswered questions about e-cigs than there are about the inhalator, but I don't think it's a balanced view of the evidence to say the potential risks or benefits of e-cigs are *totally* unknown. We do know some things, and we also have a pretty reasonable idea of what we need to get answers to in order to satisfy safety/efficacy questions (many of which are actually set out in an article published in this journal http://bit.ly/m5oFGP ).

If we got answers to some of these questions and it was reasonably clear in the literature that the product was a satisfactory alternative for current smokers; it wouldn't be harmful to never-users/attractive to children etc; and balanced safety/effective at least as well as current nicotine products, I'm struggling to see how they can't be a part of the solution.

Australia is unique (maybe not unique but in the lead) in its utter disregard for smokers who cannot or do not wish to quit. E-cigarettes and smokeless tobacco (banned in a country that allows cigarettes!) are the lights at the end of the nicotine use tunnel. Relatively safe nicotine use is possible thanks to these options. Your focus on addiction indicates that health is not your primary concern when it comes to tobacco use. In your own words, we may be just around the corner from “nicotine addiction as a harmless and fun activity”. Or is coffee on your radar as another pernicious pastime?

Gmoney

Translation:

Smoking is icky. E-cigs look like smoking to me, so they are icky. I don't care about facts or evidence or science stuff. I don't care if millions of “smokers” die, I just don't want to see people doing something that looks icky!

ruthmalone

I am out of the office until May 5. I will be unable to check email consistently during this time. I will respond to your message as soon as possible or on my return–thanks for your patience. Should you need immediate assistance with UCSF matters, please contact Regina Gudelunas, 415-476-3273. If this is a Tobacco Control journal matter, contact journal staff at tobaccocontrol@bmj.com

Becky: Before writing about how you fear they might be used, you might want to take a look at some of the surveys of e-cigarette users to find out how they actually are being used. The most recent of these was Siegel, et al, in the April 2011 issue of the American Journal of Preventive Medicine: “Thirty-one percent (31.0%) of respondents were not smoking at the 6-month point.Of those who were not smoking at 6 months, 56.7% were using e-cigarettes, 9.0% were using tobaccofree nicotine products, and 34.3% were completely nicotine-free. Smoking abstinence rates generally increased with higher frequency of e-cigarette use, with more than two thirds (70.0%) of respondents using e-cigarettes more than 20 times per day being nonsmokers at 6 months.” http://www.ajpm-online.net/web…

An earlier survey by Heavner, et al found that 79% were using e-cigarettes as a complete replacement for all their tobacco cigarettes, with another 17% using them as a partial replacement. Only 4% were using them in addition to tobacco cigarettes. http://tobaccoharmreduction.or…

A major difference between the two groups surveyed is that the most recent one contacted customers who purchased a particular brand, where the other one surveyed people using a variety of brands and who also received help and advice from an online forum.

When used as directed, NRT products have a 7% success rate at 6 months, dropping to 5% at one year, and to 2% at 20 months. (Moore D, et al. Effectiveness and safety of nicotine replacement therapy assisted reduction to stop smoking: systematic review and meta-analysis. BMJ 338:b1024 2009 http://www.bmj.com/content/338…

The problem with the approved smoking cessation products is that all require complete nicotine abstinence, which is unsustainable for a large percentage of the remaining smoking population. I understand your concern that “These products may also encourage smokers who would have otherwise have completely quit, to keep smoking.” What do you measn by “keep smoking”? Vapor is not smoke. Those who completely switch to an e-cigarette are no longer smokers.

On the other hand, given the abysmal success rate (comparatively speaking) of the nicotine abstinence approach, have you considered that insisting on nicotine cessation may discourage smokers who otherwise whould have quit (by switching to a less harmful alterantive source of nicotine) to keep on smoking?

As we see from the results of these surveys, those who can give up nicotine do so at some point after switching. If you look at the demographics of these folks, you will see that e-cigarette users smoked for decades and tried over and over to “be good” and give up nicotine. They had almost given up hope of ever being able to quit smoking until they switched to an e-cigarette. Some who did quit smoking had no intention of doing so when they first began using the products.

These products are not part of the problem. Folks who insist on “quit (nicotine) or die” are the problem. As one who smoked for 45 years before switching completely to an e-cigarette two years ago, I have to say that I'd rather switch than die.

ruthmalone

I am out of the office until May 5. I will be unable to check email consistently during this time. I will respond to your message as soon as possible or on my return–thanks for your patience. Should you need immediate assistance with UCSF matters, please contact Regina Gudelunas, 415-476-3273. If this is a Tobacco Control journal matter, contact journal staff at tobaccocontrol@bmj.com

If “smoking” e-cigarettes is harmless (and for all we know, it is) why shouldn't people go on doing it, for pleasure, indefinitely? There is a horrible Puritan, controlling tendency in the mind of the writer of this article.

ruthmalone

I am out of the office until May 5. I will be unable to check email consistently during this time. I will respond to your message as soon as possible or on my return–thanks for your patience. Should you need immediate assistance with UCSF matters, please contact Regina Gudelunas, 415-476-3273. If this is a Tobacco Control journal matter, contact journal staff at tobaccocontrol@bmj.com

I tried many times to quit smoking using patches and gum, but it simply didn't work. I finally managed to quit using Swedish Snus. I do not have any experience with e-cigs, but from what I read, they also work.

There is some big noise about e-cigs and Snus (which is banned in the EU). They are considered dangerous to public health. But from what I can see, the only thing which sets them apart from pharma products is that they do work.

There seem to be forces which try to implement the belief, that products which actually help people to quit smoking are bad, and only the ones which do not work are good. This makes be believe that these forces do not really want a smoke-free world. The repentant smoker, who fails time and again to quit smoking seems to be more desirable.

ruthmalone

I am out of the office until May 5. I will be unable to check email consistently during this time. I will respond to your message as soon as possible or on my return–thanks for your patience. Should you need immediate assistance with UCSF matters, please contact Regina Gudelunas, 415-476-3273. If this is a Tobacco Control journal matter, contact journal staff at tobaccocontrol@bmj.com

Nicotine is present in everyday foods such as tomatoes, potatoes and cauliflower and like a lot of things is not harmful unless taken in the extreme. the smoking of tobacco products means that you are inhaling Carcinogens’ in addition to the nicotine, which are harmful. Secondly E cigarettes are usually used by people who enjoy the act of smoking and don't wish to give up but either or want to avoid the unhealthy apsect, be able to imbibe without having to be ostrasised as a dirty filthy smoker, though where the rightous are concerned the latter probably doesn't make much difference. And no I am not a smoker .

ruthmalone

I am out of the office until May 5. I will be unable to check email consistently during this time. I will respond to your message as soon as possible or on my return–thanks for your patience. Should you need immediate assistance with UCSF matters, please contact Regina Gudelunas, 415-476-3273. If this is a Tobacco Control journal matter, contact journal staff at tobaccocontrol@bmj.com

I am out of the office until May 5. I will be unable to check email consistently during this time. I will respond to your message as soon as possible or on my return–thanks for your patience. Should you need immediate assistance with UCSF matters, please contact Regina Gudelunas, 415-476-3273. If this is a Tobacco Control journal matter, contact journal staff at tobaccocontrol@bmj.com

I am out of the office until May 5. I will be unable to check email consistently during this time. I will respond to your message as soon as possible or on my return–thanks for your patience. Should you need immediate assistance with UCSF matters, please contact Regina Gudelunas, 415-476-3273. If this is a Tobacco Control journal matter, contact journal staff at tobaccocontrol@bmj.com

You go EK! And as for you, ruthmalone, I'm really disappointed in you. Your refference to celebrities being paid to smoke is not entirely the truth. In fact, truth be told, before celebs were paid to smoke, smoking was already in style. Everyone did it, and they did it everywhere. It was a designation of class. Celebs were paid to smoke a specific kind of cigarette, so that their product was promoted. It wasn't a big conspiracy by Big Tobacco to get the entire world addicted to cigarettes. That's just tinfoilhattery. It's the same here. Katherine Heigl was given the e-cig in an effort to promote one distributor's product. Depp, as far as I am aware, was not product placement at all, but instead a device of character development. I highly doubt the director would aprove your allogations of conspiracy against the health and well being of the public.

ruthmalone

I am out of the office until May 5. I will be unable to check email consistently during this time. I will respond to your message as soon as possible or on my return–thanks for your patience. Should you need immediate assistance with UCSF matters, please contact Regina Gudelunas, 415-476-3273. If this is a Tobacco Control journal matter, contact journal staff at tobaccocontrol@bmj.com

I think the fox has seen the rabbit, very little to agree with here I am afraid. Firstly I am going to disagree smoking is an addiction. On the 7th April 2011 I was a speaker at the BMJ and Pfizer sponsored The International Forum on Quality and Safety in Healthcare, Is Smoking a Disease or a Habit? The audience were mainly smoking cessation professionals and the room initially voted that it was a disease but at the end was evenly split. Apart from Dr. Reuben Dar’s papers, most of my evidence came from ASH and your boss Professor Simon Chapman. His paper The Global Research Neglect of Unassisted Smoking Cessation: Causes and Consequences where his own and other paper’s conclusions were:

“Research shows that two-thirds to three-quarters of ex-smokers stop unaided,”

In 1986, the American Cancer Society reported that: “Over 90% of the estimated 37 million people who have stopped smoking in this country since the Surgeon General’s first report linking smoking to cancer have done so unaided.

“Research shows that two-thirds to three-quarters of ex-smokers stop unaided,” and that “53% of the ex-smokers said that it was “not at all difficult” to stop, 27% said it was “fairly difficult”, and the remainder found it very difficult.”

Becky you seem to be a minority voice. When anti smokers such as Bill Godshall, Executive Director of Smokefree Pennsylvania, in sending a letter directly to the New Jersey senate, stating, “Proponents of [the bill banning indoor use] have grossly and intentionally misrepresented the health risks of e-cigarettes in order to scare legislators into voting for this unwarranted legislation that threatens (instead of improves) public health. Smokers who have recently quit and/or are trying to quit need support, not harassment and ostracism.”

“Selling smokers unfounded promises of a miracle cure cannot be a foundation for public health policy.”

NRT hardly fits the bill does it? With success rates as low as 1.6% as is written in a letter to the British Medical Journal (BMJ) by Professor Michael Siegel. A more recent study piles on the agony at 0.8%, “The actual number of subjects who achieved one-year continuous abstinence with the nicotine patch was 5, or only 0.8% of the sample.” This in the BMJ study stated “The long term (that is, greater than six months) quit rates for OTC NRT was 1% and 6% in two studies and 8–11% in five other studies. These results were not homogenous; however, when combined the estimated OR was 7% (95% CI 4% to 11%). Conclusions: OTC NRT is pharmacologically efficacious and produces modest quit rates similar to that seen in real world prescription practice.”

Becky if you really want to reduce tobacco consumption you are going to have to embrace E cigarettes and/or snus. Failing that smoking rates will remain stubbornly high, surely that is not your aim.

I am out of the office until May 5. I will be unable to check email consistently during this time. I will respond to your message as soon as possible or on my return–thanks for your patience. Should you need immediate assistance with UCSF matters, please contact Regina Gudelunas, 415-476-3273. If this is a Tobacco Control journal matter, contact journal staff at tobaccocontrol@bmj.com

Will you quit with your spamming ruthmalone. Either fix your flipping spambot or get the out of here. All this shows is that you don't even know how to control your computer so how on earth are you able to control scientific instruments or even learn to read manuals and documents.

Rant over.

ruthmalone

I am out of the office until May 5. I will be unable to check email consistently during this time. I will respond to your message as soon as possible or on my return–thanks for your patience. Should you need immediate assistance with UCSF matters, please contact Regina Gudelunas, 415-476-3273. If this is a Tobacco Control journal matter, contact journal staff at tobaccocontrol@bmj.com

Will you quit with your spamming ruthmalone. Either fix your flipping spambot or get the out of here. All this shows is that you don't even know how to control your computer so how on earth are you able to control scientific instruments or even learn to read manuals and documents.

Rant over.

ruthmalone

I am out of the office until May 5. I will be unable to check email consistently during this time. I will respond to your message as soon as possible or on my return–thanks for your patience. Should you need immediate assistance with UCSF matters, please contact Regina Gudelunas, 415-476-3273. If this is a Tobacco Control journal matter, contact journal staff at tobaccocontrol@bmj.com

The continuing exaggerations and lies continue to astound. It cannot go on for ever. Sooner or later the lies will be found out.

Second hand smoke is harmless. Umpteen studies have shown that.

Ecigs are harmless in every respect. Where do the eugenicists get the right to even propose that they be questioned? What people do is their decision and their responsibility.

The sooner that we get rid of the leaches in Tobacco Control worldwide, the better.

ruthmalone

I am out of the office until May 5. I will be unable to check email consistently during this time. I will respond to your message as soon as possible or on my return–thanks for your patience. Should you need immediate assistance with UCSF matters, please contact Regina Gudelunas, 415-476-3273. If this is a Tobacco Control journal matter, contact journal staff at tobaccocontrol@bmj.com

In a few months time, I am going on a cruise on an American boat. The oppurtunities for the enjoyment of tobacco is strickly limited. In those circumstances, do you not think that the fact that ecigs are welcome for use on the boat is a good thing? After all, one does not pay over a thousand pounds for such a trip and wish to suffer withdrawal symptoms!

I can only comment from personal experience. My other half generally consumes over 60+ rollies a day. He had to migrate from cigarettes to rollies due to cost. I introduced him to the e-cig before a long haul flight. He is now smoking his duty free cigarettes when he wants but uses the e-cig most the time, indoors and in the car. His actual cigarette consumption has more than halved.I bought my son the e-cg after he had tried his father's and whilst he is also smoking the duty-free cigarettes he plans to migrate to the e-cig full time and is even contemplating dropping the nicotine content in the vapor.So from experience the e-cig is a big plus. Neither would have cut down using any other method. If controls are put on the use of e-cigs it will show beyond doubt that anti-smoking is more about control than health.

online smoke shop

If you wish to keep severe health implications like cancer, stress and so forth away then you definitely should resort to electronic cigarette because it is a healthy way to smoke. Both men and women will look stylish and remain healthy if they pull a drag from e-cigarette. It is the most secure and healthiest approach to smoke and luxuriate in life. youtube.com/user/smokewire

they are a solution to quit smoking tabacco, no matter the way you see it tobacco is worse than ecigs,. I only buy electronic cigarettes, and I can feel the difference in my breathing,. I feel much better now,. only a first hand experience could tell you exactly what its felt,.

Ekeller

“These products may also encourage smokers who would have otherwise have completely quit, to keep smoking.” Two points: 1) If a smoker switches completely to e-cigarette vapor, he or she is no longer inhaling smoke. Therefore he or she is no longer smoking. 2) Do not assume that eventually every smoker will quit. I know smokers in their 50s and 60s who have tried over and over and cannot quit. I know smokers in their 80s who just plain don't want to quit. Wouldn't it be better for those folks to eliminate the most harmful elements of smoke from what they inhale?

An e-cigarette user no longer inhales the tar, CO, particulates, and thousands of chemicals created by the process of combustion. Other than water, flavoring, and propylene glycol (considered Generally Recognized as Safe (GRAS) by the FDA, the only smoke-related chemical being inhaled by an e-cigarette user is nicotine. (Part 1 of 2)

Ekeller

Nicotine does not cause cancer, cardiovascular disease, or lung disease when delivered via smoke-free alternatives. Users of low-nitrosamine smokeless tobacco have no higher rates of smoking-related disease than former smokers who gave up all use of tobacco/nicotine. Smoking-related diseases are unknown in long term users of pharmaceutical nicotine products.

Unlike other drugs we call “addictive”, nicotine is not intoxicating. It does not impair thinking, judgment, memory, and concentration. It provides some of the same beneficial effects as caffiene: improves attention and concentration and relieves fatique and stress. Nicotine is also a powerful anti-depressant, reliving depression in some of the 30% of patients treated with anti-depressants who are still experiencing symptoms of depression.

So, the argument that these products might discourage smokers quitting just doesn't hold water. These products might be the one thing that finally enables some smokers to quit. (Part 2 of 2)

Ask a smoker to quit smoking i am 100 percent sure he won’t be able to do that, provide that smoker an electronic cigarette and asks him to smoke it instead of traditional cigarette, after a few months he will be free from tobacco addiction, so i think ecigs are the best solution out there if you want to quit easily.

Not everybody has strong will power to quit smoking quickly, this is where electronic cigarette becomes helpful, they can help you to do that easily.

David Holland

It seems to me that while the anti brigade are arguing that e-cigs might not be 100% safe compared with not smoking, when you compare e-cigs with tobacco smoke, they are far less harmful for a smoker. On that basis they have to be a step in the right direction. As a smoker, for me it is all about mitigating the risks as much as possible http://bit.ly/ZvDDWr

The fact is that there have been no reports of serious health issues from use of an e-cigarette to date. The product has been widely available since 2007. If harm from the product arises it will be in the long term. This also goes for the patch or gum. When you say that e-cigarettes haven’t went through the rigorous testing that NRTs have, you fail to mention that they don’t test the long term effects of those products either…..because they can’t. Everything has risk and as long as all known risks are disclosed and the product is monitored (which all products now-a-days are) then it is up to the user to determine what they find acceptable.